Rickettsioses are zoonoses transmitted by vectors. More than one agent can coexist in vectors. Although vectors may transmit more than one microorganism to humans, information on dual infections is scarce. We present a case of a patient with an atypical rickettsiosis diagnosis in whom two species of Rickettsia were detected.
CASE REPORTA 46-year-old woman was admitted to Bellvitge University Hospital in May with fever (38°C) as well as a retroauricular adenopathy and a subsequent preauricular and lateral cervical adenopathy that had lasted for 10 days. On examination at admission, she was afebrile and she had a necrotic eschar on the scalp (tache noire), face swelling, and a rash on her upper extremities. Laboratory examination showed normal values, except for the presence of activated lymphocytes and increased levels of alanine aminotransferase/aspartate aminotransferase, lactate dehydrogenase, and gamma-glutamyl transpeptidase. Testing of the patient's serum for toxoplasma and cytomegalovirus were negative. She reported that she had a dog and she had observed ticks on it recently.Tick-borne lymphadenopathy (TIBOLA) (recently called scalp eschar and neck lymphadenopathy syndrome [SENLAT]) caused by Rickettsia slovaca was suspected. As a consequence, a regimen of doxycycline (100 mg every 12 h for 4 days) was prescribed. The patient's condition improved. She was discharged 5 days after admission. The patient underwent periodical clinical evaluations for 49 days until her symptoms resolved completely.At admission, an acute-phase serum sample, a blood sample, and a scalp eschar biopsy specimen were collected. Serum was evaluated by indirect immunofluorescence assay (IFA).Antibodies against Rickettsia conorii were tested for using a commercial antigen (R. conorii spot; bioMérieux, Marcy l'Étoile, France). Antibodies against R. slovaca were tested for using an R. slovaca antigen kindly provided by the Unité de Rickettsies, Marseille, France. IgG antibodies against R. conorii antigen (titer Ͼ 5,120) were detected, whereas the IFA using R. slovaca antigen was negative. As neither clinical nor epidemiological variables were typical of Mediterranean spotted fever (MSF, whose etiological agent is R. conorii), and IFA for R. slovaca was not positive, a more accurate diagnosis was carried out.DNA was obtained from the whole-blood sample, the scalp eschar biopsy specimen, and the liquid that contained the scalp eschar biopsy specimen. For this purpose, the MasterPure DNA purification kit (Epicentre, Madison, WI) was used. PCR assays targeting the rickettsial genes for the citrate synthase (gltA) and the outer membrane protein A (ompA), were performed (Table 1). For the citrate synthase gene (gltA), primer CS890r and a new primer (CS214_for), designed by our team, were used. For the ompA gene, a real-time PCR was designed by our team using a new pair of primers: Rr190.314 and Rr190.630. In addition, another pair of primers was used (Rr190.70 and Rr190.701). This set of primers amplifies a bigger fragment that includes the on...